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Fig. 7.12c. The right common iliac artery has been obliterated by the chronic false lumen. The patient underwent repair of the ascending and transverse aneurysm, with circulatory arrest, resuspension of the aortic valve, and coronary bypass.

erally portend a higher chance of rupture and poor prognosis without surgery. Smaller aneurysms can generally be followed, although a size between 5-6 cm represents a gray zone. The presence of aortic insufficiency is a compelling reason for aortic replacement even for smaller aneurysms.

If an aneurysm of 5 cm diameter is found incidentally in the ascending aorta while performing another cardiac procedure, one of several acceptable choices must be made. There is justification for either not performing any aortic intervention or alternatively placing Dacron mesh around the aorta for additional support. Some advocate replacement of the ascending aorta at this point, although

Fig. 7.13a. The aneurysmal ascending aorta of a 3 year old child with Marfan's syndrome. The cross-clamp can still be applied to the distal ascending aorta and bypass achieved into the transverse arch. Courtesy of Dr Jeff Milliken, Harbor-UCLA

Fig. 7.13b. The aorta is opened and the regurgitant aortic valve excised. Courtesy of Dr. Jeff Milliken, Harbor-UCLA.

this is usually not warranted. A reduction aortoplasty is also a valid alternative. Technique of Repair

For ascending aortic aneurysms, if the aneurysm does not extend beyond the origin of the innominate artery, one may be able to place the arterial cannula in the distal ascending aorta or transverse arch and initiate cardiopulmonary bypass with inflow from the right atrium. A cross-clamp is placed proximal to the innominate artery, and adequate perfusion of the arch vessels is achieved (Fig. 7.11a-d, 7.13a-c). If the ascending aortic aneurysm extends distal to the innominate, it will be impossible to properly clamp proximal to the innominate artery. In this case, right atrial-femoral arterial cardiopulmonary bypass is established.

As for acute aortic dissection, several well-defined management decisions must be made with regard to the aortic valve, coronary arteries, and transverse arch. If the aortic valve must be repaired or replaced but the coronaries are spared, a separate supracoronary tube graft may be placed. As mentioned in the section on acute

Fig. 7.14. Transverse arch aneurysm repair. (a) Interposition technique with great vessels attached to graft as a separate patch or included within the distal anastomosis.

Fig. 7.15a. CT scan of a 35 year old female with a large descending thoracic aneurysm with mural clot. Courtesy of Dr Jeff Milliken, Harbor-UCLA.

Fig. 7.15b. A left thoracotomy reveals the large sized aneurysm. Courtesy of Dr Jeff Milliken, Harbor-UCLA.

Fig. 7.15c. Left atrial-femoral partial bypass is established. The left atrial can-nula is seen in position. The vagus and phrenic nerves are retracted with vascular tapes. Courtesy of Dr Jeff Milliken, Harbor-UCLA.

Fig. 7.16a-b. Chest and abdominal CT of a large thoracoabdominal aneurysm. The aneurysm was repaired under left atrial-femoral bypass. The proximal anastomosis was done through a left fourth interspace approach. The distal anastomosis was done through a left ninth thoracoabdominal approach.

Fig. 7.16a-b. Chest and abdominal CT of a large thoracoabdominal aneurysm. The aneurysm was repaired under left atrial-femoral bypass. The proximal anastomosis was done through a left fourth interspace approach. The distal anastomosis was done through a left ninth thoracoabdominal approach.

dissection, for Marfan patients, a valve replacement should be done as a valved conduit rather than as an isolated aortic valve replacement and supracoronary conduit. This is to prevent the chance of degeneration of the remaining aortic segment with the coronaries. If the coronaries must be reimplanted, a Bentall or Cabrol procedure is performed (Fig. 7.11a-d, 7.13a-c). If the transverse arch is

Fig. 7.17. Thoracoabdominal aneurysm resection. (a) Left atrial-femoral bypass established. Cross-clamps placed proximally at [A] and [B] while perfusing visceral and spinal vessels. The proximal anastomosis is performed during left atrial-femo-ral bypass. (b) After the proximal anastomosis has been performed, the bypass pump is turned off, the clamp at [B] is removed and the clamp at [A] is removed and placed on the graft. (c) The visceral vessels are implanted in the graft. (d) After the visceral vessels are reimplanted, the distal graft is clamped and the proximal clamp at [A] is removed. The distal anastomosis is performed while the visceral and spinal vessels are reperfusing. (e) Completed repair.